Chapter 3 Section 4.1. Defense Enrollment Eligibility Reporting System (DEERS) Concepts

Transcription

1 Defense Enrollment Eligibility Reporting System (DEERS) Chapter 3 Section 4.1 Defense Enrollment Eligibility Reporting System (DEERS) Concepts Revision: 1.0 APPLICATION 1.1 This section provides general guidance for all contractors that interface with the DEERS in support of their contractual requirements 1.2 See also Sections 1.1 and For the purpose of defining geographical areas the 50 United States (U.S.) and the District of Columbia are hereafter referred to as the Continental United States or CONUS; all areas Outside of CONUS are considered OCONUS. 1.4 This section describes the following: Terminology used within DEERS (also, see the TRICARE Operations Manual (TOM), Appendix A). Methodology for identifying individuals and their roles within DEERS. Functional data components within DEERS (e.g., eligibility, enrollment (Health Care Delivery Program (HCDP) plans with premiums/fees, claims, Catastrophic Cap and Deductible Data (CCDD), Other Health Insurance (OHI)). 2.0 CONTRACTOR RESPONSIBILITY Contractors shall understand and execute the DEERS concepts described in this section. The contractor shall consult with DEERS and Defense Health Agency (DHA) if clarification is required. 3.0 DEERS DATA USE CONCEPTS 3.1 All DEERS data provided by the Defense Manpower Data Center (DMDC) to the DHA for the use of determining medical eligibility, enrollment, and health care claims payment are subject to the Privacy Act of 1974, as amended. DEERS data includes all data that is provided for test and/or production activities. 3.2 Release is made to all globally executed TRICARE program support contractors (hereafter referred to as contractors ) in accordance with the provisions of the Privacy Act allowing for intra- 1

2 department release when an appropriate need to know exists. As such, the authorized organizations are responsible for using the protected Privacy Act data in accordance with the applicable provisions of the Privacy Act or the DHA comparable approved or accepted security check process for overseas contractors accessible by personnel with at least an Automated Data Processing/Information Technology-II (ADP/IT-II) designation. 3.3 This includes: Only personnel (military, civilian, contractor) with a need to know in the official performance of their duties may be given access, and the data may only be used for the specific purposes agreed to by DMDC and DHA The contractors/organizations to which these data are provided shall insure that sufficient physical and procedural safeguards are in place to satisfy the requirements of the Privacy Act These data should be returned to DMDC or destroyed when the approved use has been accomplished and no copies should be retained Any additional intended uses must first be submitted through DHA to DMDC for approval and are prohibited unless and until favorably coordinated with DMDC In addition, DMDC only provides the DEERS data for specific purposes, such as: Eligibility data is for reporting the eligibility of a beneficiary on DEERS as of the time of the eligibility inquiry Enrollment data is for the authorized enrollment of beneficiaries into valid HCDPs as defined under the provisions of the respective Request For Proposal (RFP)/contract Claims data is for the processing and resolution of claims submitted for reimbursement of health care received CDDD for the processing and resolution of Catastrophic Cap and Deductible (CC&D) information resulting from heath care services received OHI and Standard Insurance Table (SIT) data for the processing and resolution of OHI resulting of and from heath care services received. 4.0 DEERS SYSTEM OVERVIEW 4.1 Program Description DEERS serves as a centralized Department of Defense (DoD) data repository of personnel and medical data. The DEERS database contains detailed personnel eligibility information for benefits and entitlements distribution to Uniformed Services 1 members; U. S. sponsored Foreign Military members; DoD and Uniformed Services civilians; other personnel as directed by the DoD; and their 1 The seven Uniformed Services are: U.S. Army (USA), U.S. Navy (USN), U.S. Marine Corps (USMC), U.S. Air Force (USAF), U.S. Coast Guard (USCG), their National Guard (NG) and Reserve Components (RC), U.S.Public Health Service (USPHS), and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Corps. 2

3 eligible family members. DEERS supports essential day-to-day operations in a broad range of functional areas, including personnel, benefit entitlements, pharmacy, dental, medical, and finance DEERS is updated by transactions from the Uniformed Services personnel, finance, medical, and mobilization management systems, the Department of Veterans Affairs (DVA), and the Centers for Medicare and Medicaid Services (CMS). DEERS is also accessed and updated by on-line DEERS client applications, such as the Real-Time Automated Personnel Identification System (RAPIDS), and interfacing client systems of the Military Health System (MHS), such as Military Treatment Facility (MTF)/Enhanced Multi-Service Market (emsm) clinical, patient appointing, and Referral Management (RM) systems/applications. DEERS helps detect and prevent fraud and abuse in DoD benefits and entitlements distribution DEERS provides and receives updates to enrollment and eligibility verification data from existing DEERS applications and interfacing information systems, as well as from other DoD, Uniformed Services, and non-dod information systems, in accordance with DoD Directive (DoDD) It provides statistical and demographic data to support DoD and Uniformed Services peacetime and wartime missions. DEERS maintains casualty identification data on members of the Uniformed Services, and other personnel as designated by DoD, to support casualty identification and verification of entitlement eligibility for surviving family members. 5.0 DEERS SYSTEM DESCRIPTION DEERS is a person-centric system that contains information about all DoD beneficiaries plus information about some people who are not eligible for DoD benefits. Within DEERS, interfaces with external systems are based on commercial standards where it supports the business requirements or standardized DEERS defined messages where needed. DEERS data provided by DMDC to DHA is also considered Protected Health Information (PHI) as the term is defined in the Health and Human Services (HHS) Health Insurance Portability and Accountability Act (HIPAA) Privacy Final Rule and accordingly is subject to the requirements of DoD R which implements that rule for DoD and through the use of DHA business associate agreements to contractors and other non-dod entities. 6.0 TRICARE POPULATIONS The TRICARE programs serve a wide range of beneficiaries holding various statuses throughout their lifetime. The following information details the populations covered by the TRICARE benefit. The definition of the populations may be modified as legislation or DHA requires. These populations include: 6.1 Service members and Active Duty Family Members (ADFMs). These may include members from both the active duty and RC. Note: The term active duty is inclusive of full-time active duty and RC on orders of 30 days or more. Plus, the term RC is inclusive both the Reserves and NG. 6.2 Transitional Assistance Management Program (TAMP) sponsors and family members. 6.3 Selected Reserve members and their family members. 3

4 6.4 Retired sponsors and family members. Retirees eligible for retirement pay and their family members as well as Medal of Honor (MOH) recipients. 6.5 Survivors of Service members. When an active duty sponsor dies (Includes activated NG/ Reserve members), spouses and children become transitional survivors. As transitional survivors, surviving family members remain eligible for TRICARE as ADFMs. This means that health plan options and costs will not change. After three years, the surviving spouse's coverage will change to be the same as retired family members. Children remain covered as active duty family members until they lose eligibility due to age or other reasons 6.6 Survivors of retired Service members. If a sponsor dies after retiring from active duty (either regular or a medical retirement) their surviving family members remain eligible for TRICARE with the same health plan options and costs they had before their sponsor passed away. 6.7 Survivors of non-activated NG/Reserve members. If an NG or Reserve sponsor dies when not on active duty, surviving family members are only eligible for continued TRICARE health benefits if the sponsor was covered by TRICARE Reserve Select (TRS) or under the TAMP when he or she died. 6.8 Survivors of retired NG or Reserve members. If a retired NG or Reserve member dies, surviving family members may qualify for TRICARE benefits if the sponsor was covered by TRICARE Retired Reserve (TRR) at the time he or she passed away. 7.0 IDENTIFICATION SCHEMA FOR ELECTRONIC DATA INTERCHANGE (EDI) 7.1 Primary And Secondary Identifiers Identification of persons in the DEERS database is established via the two DoD required identifiers; DoD Identification Number and DoD Benefits Number (DBN). See Section 3.1 for additional information on beneficiary identification. The use of these two identifiers allows for proper exchange between systems and software. 7.2 Beneficiary Identification DEERS is the definitive system for person identification for DoD benefits and entitlements. Every beneficiary in DEERS that is authorized DoD benefits will have a DBN. See also paragraph A person may have more than one DBN, stemming from multiple entitlements over time and some of these instances are described in paragraph Patient Identification As discussed in paragraphs 9.3 and 9.4, there are situational difference between a beneficiary and a patient, which can affect the data storage/retrieval within the MHS information systems. The contractor is to use the identifiers of DoD Identification Number and DBN to support their execution of contracted health care service delivery. 4

5 7.4 Person Identification and Secondary Identification Should a beneficiary or patient not show a DBN, secondary identifiers may be used. The secondary identifiers are: Sponsor s Social Security Number (SSN) or DoD Identification Number. First three characters of the last name. Date of Birth (DOB) Any one secondary identifier, such as the sponsor SSN, could be duplicated across several beneficiaries. Therefore, each beneficiary must be positively identified using a DMDC interface/ application and at least two secondary identifiers. 8.0 TYPES OF DATA THAT DEERS USES AND STORES DEERS stores different categories of information, including Person/Personnel, Beneficiary, and Health Care Benefit. Each is detailed below. 8.1 Person/Personnel Information This is basic characteristic data about individuals, including both affiliations to DoD organizations or organizations designated by DoD, and affiliations within family units. Although historical data is available for longitudinal studies and demographic trend analysis, only current data is required for day-to-day health care operations Person Data Primary (internal) identification - A mutually agreed-upon internal identifier shared between the repository and DoD approved external interfacing systems, i.e., Electronic Data Interchange Personal Identifier (EDIPI), also known as the DoD Identification Number. Secondary (external) identification - Name, DOB, and SSN (contractors use of SSN is by DEERS and DHA approval only). General characteristics - Sex, blood type, etc. Person-based programs - Organ donor. Family association - Self, child, etc. Contact information - Address, telephone number Personnel Data Personnel category - active duty, reserve, retired, etc. Service or organization - Army, Navy, DoD civilians, etc. Position - Rank. Personnel readiness programs - Deoxyribonucleic Acid (DNA), blood type. 5

6 8.2 Beneficiary Information TRICARE Systems Manual M, April 1, This information combines the underlying rules-based system that captures DoDI Identification (ID) Cards for Members of the Uniformed Services, Their Dependents, and Other Eligible Individuals and other applicable regulations and procedures with enrollment information, as maintained by the MHS community. When the beneficiary is eligible for DoD benefits, they will have a DBN. This data is provided for past, current, and future periods from the inquiry date, and consists of specific HCDP information Examples of this information are: DoD HCDPs: DoD HCDPs are defined by DEERS as the methods of providing basic health benefits. These HCDPs indicate eligibility and/or enrollment for the following. (examples only); TRICARE Pharmacy (TPharm), TRICARE Prime, TRICARE Plus, TRS, and Continued Health Care Benefit Program (CHCBP). Other Government Programs (OGPs): OGP are defined by DEERS as programs or plans provided and supported by a U.S. Government agency other than the DoD. Commercial OHI: OHI information is stored in DEERS to support third party collections. 8.3 Health Care Benefit Information General Policy Examples of health care benefit information that DEERS tracks on a policy level include: Enrollment fee accumulation and fee details (including fee exceptions). Deductible accumulation Person Related Examples of health care benefit information that DEERS tracks on a person level include: Enrollment fee waiver information. OHI. 9.0 SPECIFIC DEERS BENEFICIARY ROLES 9.1 Person Role An individual exists within DEERS as a person who may have multiple roles, including but not limited to: a sponsor, a family member, a beneficiary, and a patient. This implies the existence of certain attributes tied to a person that do not normally change as his or her role within the system changes. For example, a person has a name, DOB, weight, height, hair color, eye color, and an SSN. These attributes make up the information associated with the primary person identifier DoD Identification Number. Both sponsor and family member are possible but not mutually exclusive roles of a person in the DEERS database. The family member role is supported by person association and condition data that is crossreferenced to the family member s sponsor. This family affiliation is associated with the DBN identifier. 6

7 9.2 Sponsor And Family Member Roles A sponsor is any person who, as a direct affiliate or Service member of an organization within the DoD, is entitled to benefits from the DoD and who, through that affiliation or membership, may entitle his or her family members to benefits. Members of non-dod organizations whose employees are authorized DoD benefits are also sponsors, and often accord eligibility to their family members Unremarried Former Spouses (URFSs) who meet eligibility requirements are considered as sponsors and are identified by their individual identifiers; DoD Identification Number and DBN. TRICARE entitlement for an URFS is ended with the existence of an employer sponsored health plan. Contractors can identify an URFS on the DEERS claims response from their DoD Identification Number and/or DBN Abused dependents also have a distinct member category (reflected in the DBN) indicating their status. The presence of OHI does not remove an abused dependent s entitlement to TRICARE (see 32 CFR 199) DEERS defines which relationships to sponsors make individual family members eligible for benefits. Some restrictions that influence the definition of a child family member include age, degree of support by the sponsor, physical disability, and educational status. 9.3 Beneficiary Role - Multiple Entitlements/Dual Eligibility DEERS considers both sponsors and family members as beneficiaries (i.e., recipients of DoD benefits). The role of beneficiary is ambiguous, a person may be entitled to DoD benefits via his or her simultaneous association to more than one sponsor or by being a sponsor in one family while being a member of another. An example is a person that is a family member in two sponsored families at the same time. This situation occurs when both spouses in a family are sponsors. This condition is known as multiple entitlements. DEERS supports multiple entitlements by not only storing persons but any combination of their current and past associations Entitlement periods may be sequential, such as when a son or daughter of a sponsor joins a Uniformed Service and he or she becomes a sponsor. Becoming a sponsor terminates the individual s previous eligibility for benefits as a family member In some cases, the roles leading to multiple entitlements may change back and forth. For example, a child of a married reservist who moves in and out of active duty assignments may have transitory periods of entitlement to health care benefits under each sponsor. Each sponsor in this family has the potential to provide health care benefits for the family member (child) for various periods of time. Therefore, this multiple-entitled child will reflect different DBNs for each sponsorship/situation and the contractors need to ensure they have the correct DBN for the health care service encounter being reviewed or executed. The concept of dual eligibility occurs when multiple entitlements are concurrent. This situation can occur when a sponsor is both a retired sponsor and a civil servant on overseas assignment. The beneficiary would have a coverage plan as the retired sponsor and another coverage plan as the civil servant. Hence, dual eligibility results when a person is associated with more than one DoD affiliation. 7

8 9.3.4 All instances of family membership and/or sponsorship are stored as the DBN, see Section 3.1 for additional information on beneficiary identification. All information about TRICARE enrollments and policies to and from DEERS and contractors must be done using the DoD Identification Number and/or DBN (as prescribed by DEERS and DHA). Updates of all other secondary attributes including SSN (on DEERS/DHA approval), Name, or DOB are exchanged using the DoD Identification Number and/or DBN (as prescribed by DEERS and DHA) as the primary means of identification. 9.4 Patient Role The patient role results from an association or interaction between a person and a DoD health care delivery provider (Note: Civilian providers contracted by a TRICARE Program support contractor are considered DoD health care delivery providers.). It is important to note that a person is not required to be currently eligible for DoD benefits to be considered a patient. For example, the patient may have been a beneficiary in the past but is no longer eligible for DoD benefits. In certain cases, an individual who is not an authorized DoD beneficiary may be treated in an emergency situation at a DoD MTF/ emsm, and is therefore a patient. Persons on DEERS and on clinical systems within the DoD are identified in the patient role by the DoD Identification Number. All clinical data must be exchanged using the DoD Identification Number. Thus, in addition to the DBN, contractors must also store the DoD Identification Number associated with each beneficiary on their database. 9.5 Beneficiary Roles Within HCDPs Subscriber Role A subscriber is an individual who is the primary holder of a DoD policy (i.e., the primary holder of a DoD entitlement) for health care benefits based on his or her affiliation with the DoD. The subscriber is the sponsor Insured Role An insured is an individual who is covered by a Uniformed Services health benefits program (i.e., an HCDP) for health care coverage. The individual is entitled to these programs based upon his or her association to a subscriber. A person may be both a subscriber and an insured. For example, under TRICARE Prime Individual Coverage for Retired Sponsors and Family Members, the sponsor is both the subscriber and an insured. However, other sponsors may be a subscriber and not be an insured. For example, a sponsor on active duty may be the subscriber for his or her family members that are insured under TRICARE Prime Family Coverage for ADFMs. 9.6 Sponsor, Subscriber, Beneficiary, And Insured Roles As a sponsor, the person may also be the subscriber who holds the DoD policy for health care benefits. As a beneficiary, the person may also be an insured who is covered by a DoD policy for health care benefits. 9.7 Family Member, Beneficiary, and Insured Roles As a sponsor, the person may also be the subscriber who holds the DoD policy for health care benefits. Another person, through associations and relationships, may be a family member to the sponsor, which implies a role as a beneficiary. As a beneficiary, the person may also be an insured who 8

9 is covered by a DoD policy for health care benefits TYPES OF HCDP PLANS HCDP plans are methods of providing pharmacy, dental, and medical benefits. Coverage under these programs may be either individual or family, depending on the number of beneficiaries enrolled and beneficiaries affiliation to the sponsor, as well as the program definition There are two types of plans within DEERS: Assigned and Enrolled Assigned plans represent the base entitlement of a beneficiary (e.g., TRICARE Standard and Pharmacy). Dental plans (e.g., TRICARE Dental Program (TDP), is done by enrollment and thus not assigned (see paragraphs and 10.3). Assigned plans are based on a sponsor s affiliation to a DoD organization (e.g., Army active duty); therefore, when a sponsor s DoD affiliation changes (e.g., Army active duty to Army Reserves), a new assigned plan is created for both the service member and family members. Note: TRICARE Extra allows a beneficiary eligible for TRICARE Standard to seek care from a TRICARE network provider, thus obtaining a discount on services and reduced cost-share. Since TRICARE Extra acts like TRICARE Standard for DEERS purposes, DEERS does not track this option Enrolled plans represent another level of benefit into which the beneficiary has elected enrollment (e.g., TDP, TRICARE Prime, TRS, TRICARE Young Adult (TYA), etc) Pharmacy HCDP (Assigned And Enrolled) Contractors are required to implement a system that allows changes to pharmacy plans and HCDP plan coverage codes as legislation and regulation require TPharm benefits, assigned only at this time The TPharm benefit includes MTF/eMSM, mail order, and retail prescription services, medications provided by physicians and other appropriate clinicians, and pharmaceutical agents provided in support of home health care The TPharm Benefits Program is available to all TRICARE eligible beneficiaries. Eligible beneficiaries need not enroll in order to use the pharmacy program. The TPharm contractor will use DEERS to verify TRICARE eligibility prior to dispensing pharmaceuticals (or paying any claim) for all beneficiaries. The TPharm contractor will also update OHI and CC&D Dental HCDP (Assigned And Enrolled) Contractors are required to implement a system that allows changes to dental plans and HCDP plan coverage codes as legislation and regulation require. 9

10 Active Duty Dental Program (ADDP) (And Associated Remote Active Duty Dental Program (RADDP)) The ADDP provides worldwide dental coverage to all Service Members of the Uniformed Services, eligible members of the Reserves and NG, and those Foreign Force Members (FFMs) eligible for care pursuant to an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PFP) SOFA). The Uniformed Services include the USA, the USN, the USAF, the USMC, the USCG, the Commissioned Corps of NOAA, and the Commissioned Corps of USPHS. The Commissioned Corps of the USPHS is not included in this program. The ADDP shall supplement care provided in the DoD s Dental Treatment Facilities (DTFs), and shall provide care to those Service members living in regions without access to DTFs (i.e., RADDP) The ADDP has two components: TDP Service members referred from military DTFs for civilian dental care; and Service members having a duty location and residence greater than 50 miles from a DTF will be required to comply with the requirements and limitations of the RADDP before receiving dental care The TDP is a voluntary dental insurance program that is available to ADFMs, Selected Reserve and Individual Ready Reserve (IRR) members, and their eligible family members TDP offers worldwide (CONUS and OCONUS) coverage to all eligible family members of Uniformed Service active duty personnel and to members of the Selected Reserve and IRR and their eligible family members. Service Members, former spouses, parents, in-laws, disabled veterans, foreign personnel, and retirees and their families are not eligible for the TDP TRICARE Retiree Dental Program (TRDP) The TRDP was authorized by Congress to provide a basic dental program for Uniformed Services retirees and their family members. Further legislation has allowed the program to be enhanced to include more comprehensive coverage. The TRDP is a voluntary dental benefits program with enrollee-paid premiums The TRDP offers coverage to all eligible personnel retired from the Uniformed Services, unremarried surviving spouses, eligible dependents, and former members of the armed forces who are MOH recipients and their immediate dependents. The TRDP currently has two programs: the Basic program which is closed to new enrollments and the Enhanced program to which all TRDP enrollees shall be enrolled. The TRDP is a worldwide program. The TRDP Basic program offers coverage for dental services rendered in CONUS, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, the Commonwealth of the Northern Mariana Islands, and Canada. TRDP enhanced program benefits are offered worldwide. 10

11 10.4 Medical HCDP (assigned and enrolled) Contractors are required to implement a system that allows changes to medical health care plans and HCDP plan coverage codes as legislation and regulation require Assigned Plans These plans are the defaults assigned by DEERS for beneficiaries based on their eligibility status. Assigned plans do not require enrollment actions Service Members - TRICARE Prime, No Primary Care Manager (PCM) Selected TRICARE Prime for Active Duty Sponsors, No PCM Assigned is the default coverage assigned by DEERS for active duty sponsors. They are entitled to Direct Care (DC), Civilian Health Care (CHC) under the Supplemental Health Care Program (SHCP), and pharmacy benefits. This plan is the default for Service members who are not enrolled in a specific MTF/eMSM or TRICARE Prime Remote (TPR). These enrollees are deemed Prime but do not have a PCM TRICARE Standard The TRICARE Standard HCDP is the basic coverage assigned by DEERS for eligible beneficiaries and results when a beneficiary under the age of 65, or 65 and over but not Medicare eligible, is entitled to both DC and CHC DC Only This plan identifies beneficiaries who are entitled only to DC in MTFs/eMSMs, on a space available basis or under TRICARE Plus enrollment (see the TOM). Examples of the eligible population include dependent parents and parents-in-law, or beneficiaries who are eligible for the Medicare benefits that do not have both Medicare Parts A and B TRICARE For Life (TFL) Beneficiaries with Medicare Parts A and B are eligible for the TFL benefit Care Plans for DoD Affiliates DoD affiliates are a conglomerate category of individuals entitled to DC or CHC at different levels than the groups defined in other HCDPs. The most commonly defined DoD Affiliates follow (may not be all-inclusive): DC within the CONUS DoD Affiliates. This health care plan is available for the following population(s): NATO Sponsored, PFP, and NATO non-sponsored Foreign Military and their family members. Non-NATO sponsored Foreign Military and their family members. 11

12 DC For OCONUS DoD Affiliates. This health care plan is available for the following population(s): NATO and non-nato Foreign Military and their family members. Civilian personnel of DoD and other Government agencies and their accompanying family members. Civilian contractors under contract to the DoD or the Uniformed Services. Uniformed and non-uniformed full-time personnel of the Red Cross and their family members. Area executives, center directors, and assistant directors of the United Service Organization (USO) and their family members. United Seaman s Service (USS) personnel and their accompanying family members. Military Sealift Command (MSC) Civil Service personnel TRICARE Standard For CONUS DoD Affiliates. This health care plan is available for the following population(s): Enrolled Plans Family members of sponsored and non-sponsored NATO Foreign Military. See the TRICARE Policy Manual (TPM) and TOM for types of CONUS and OCONUS plans and eligibility requirements. They include: TRICARE Prime (Service member) TPR (Service member) TRICARE Prime TPRADFM TRICARE Plus USFHP CHCBP TRS Program TRR Program TYA Standard TYA Prime 10.5 Special Health Care Programs DEERS supports any special health care program mandated by the DoD. These special health care programs are programs into which a beneficiary can enroll or register concurrently with other assigned or enrolled health care coverage plans to which they are entitled. Contractors may also utilize a Government furnished web-based general inquiry of DEERS system/application to obtain special program coverage information. See the TPM and the TOM for details regarding these special programs. 12

13 They include, but may not be limited to: TRICARE Extended Care Health Option (ECHO). Wounded Ill and Injured (WII). - END - 13

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